Epidural steroid following discectomy for herniated lumbar disc reduces neurological impairment and enhances recovery: a randomized study with two-year follow-up

Methylprednisolone Following Minimally Invasive Lumbar Decompression: A Large Prospective Single-Institution Study

STUDY DESIGN

Prospective randomized.

OBJECTIVE

Intraoperative methylprednisolone is a common adjunct following microscopic laminectomy/microdiscectomy. The goal of epidural instillation is a rapid symptomatic reduction in irritation of neural elements. There is inconsistent data supporting its use intraoperatively. To understand whether this maneuver results in any clinical effect, we performed a multiyear prospective study.

SUMMARY OF BACKGROUND DATA

Previous work has demonstrated equivocal effects on pain with a suggestion of an increased risk of complication. These studies tend to suffer from small sample sizes and short follow-ups.

MATERIALS AND METHODS

Study obtained IRB approval. During the study period from 2013 to 2019, nearly equivalent numbers of patients who had received steroids during MIS decompressions were followed. Primary outcomes included pain (visual analog scale) and disability [Oswestry Disability Index (ODI)] at 2 weeks and 4 months. Secondary outcomes included complications, readmissions, and reoperation rates during the study period.

RESULTS

Four hundred eighty-six patients were followed for a mean follow-up of 5.17 years. The index case was more likely to be a revision surgery in the steroid group. Across all patients, there was no difference in pain at 2 weeks or 4 months. Disability was reduced at 2 weeks in the steroid group (ODI: 16.71 vs . 21.02, P = 0.04) but not at 4 months. By subgroup analysis, this is largely explained by ODI reduction in patients with high preoperative ODI (13.00 vs . 43.43, P = 0.03). Patients in the steroid cohort were more likely to undergo subsequent spinal surgery during the study period.

CONCLUSION

Methylprednisolone instillation is associated with a large, transient reduction in ODI for patients with high preoperative ODI; there is no measurable effect on pain. There is equivocal effect on risk of subsequent reoperation. This issue was clarified in peer review but changes did not make it to the abstract. Therefore, the technique is likely best reserved for patients with significant preoperative disability.

Preoperative epidural steroid injections do not increase the risk of postoperative infection in patients undergoing lumbar decompression or fusion: a systematic review and meta-analysis

PURPOSE

Epidural corticosteroid injections (ESI) are a mainstay of nonoperative treatment for patients with lumbar spine pathology. Recent literature evaluating infection risk following ESI after elective orthopedic surgery has produced conflicting evidence. Our primary objective was to review the literature and provide a larger meta-analysis analyzing the temporal effects of steroid injections on the risk of infection following lumbar spine surgery.

METHODS

We conducted a query of the PubMed, Embase, and Scopus databases from inception until April 1, 2022 for studies evaluating the risk of infection in the setting of prior spinal steroid injections in patients undergoing lumbar spine decompression or fusion. Three meta-analyses were conducted, (1) comparing ESI within 30-days of surgery to control, (2) comparing ESI within 30-days to ESI between 1 and 3 months preoperatively, and (3) comparing any history of ESI prior to surgery to control. Tests of proportions were utilized for all comparisons between groups. Study heterogeneity was assessed via forest plots, and publication bias was assessed quantiatively via funnel plots and qualitatively with the Newcastle-Ottawa Scale.

RESULTS

Nine total studies were included, five of which demonstrated an association between ESI and postoperative infection, while four found no association. Comparison of weighted means demonstrated no significant difference in infection rates between the 30-days ESI group and control group (2.67% vs. 1.69%, p = 0.144), 30-days ESI group and the > 30-days ESI group (2.34% vs. 1.66%, p = 0.1655), or total ESI group and the control group (1.99% vs. 1.70%, p = 0.544). Heterogeneity was low for all comparisons following sensitivity analyses.

CONCLUSION

Current evidence does not implicate preoperative ESI in postoperative infection rates following lumbar fusion or decompression. Operative treatment should not be delayed due to preoperative steroid injections based on current evidence. There remains a paucity of high-quality data in the literature evaluating the impact of preoperative ESI on postoperative infection rates.

LEVEL OF EVIDENCE

II.

Outcomes of epidural steroids following percutaneous transforaminal endoscopic discectomy: a meta-analysis and systematic review

Background

Percutaneous transforaminal endoscopic discectomy (PTED) has been widely used in the treatment of lumbar degenerative diseases. Epidural injection of steroids can reduce the incidence and duration of postoperative pain in a short period of time. Although steroids are widely believed to reduce the effect of surgical trauma, the observation indicators are not uniform, especially the long-term effects, so the problem remains controversial. Therefore, the purpose of this paper was to evaluate the efficacy of epidural steroids following PTED.

Methods

We searched PubMed, Embase, and the Cochrane Database from 1980 to June 2021 to identify randomized and non-randomized controlled trials comparing epidural steroids and saline alone following PTED. The primary outcomes included postoperative pain at least 6 months as assessed using a visual analogue scale (VAS) and the Oswestry Disability Index (ODI). The secondary outcomes included length of hospital stay and the time of return to work.

Results

A total of 451 patients were included in three randomized and two non-randomized controlled trials. The primary outcomes, including VAS and ODI scores, did not differ significantly between epidural steroids following PTED and saline alone. There were no significant intergroup differences in length of hospital stay. Epidural steroids were shown to be superior in terms of the time to return to work (P < 0.001).

Conclusions

Intraoperative epidural steroids did not provide significant benefits, leg pain control, improvement in ODI scores, and length of stay in the hospital, but it can enable the patient to return to work faster.

Fragility Analysis of Statistically Significant Outcomes of Randomized Control Trials in Spine Surgery: A Systematic Review

STUDY DESIGN

Systematic review.

OBJECTIVES

The aim of this study was to assess the robustness of statistically significant outcomes from randomized control trials (RCTs) in spine surgery using Fragility Index (FI) which is a novel metric measuring the number of events upon which statistical significance of the outcome depends.

SUMMARY OF BACKGROUND DATA

Many trials in Spine surgery were characterized by fewer outcome events along with small sample size. FI helps us identify the robustness of the results from such studies with statistically significant dichotomous outcomes.

METHODS

We conducted independent and in duplicate, a systematic review of published RCTs in spine surgery from PubMed Central, Embase, and Cochrane Database. RCTs with 1:1 prospective study design and reporting statistically significant dichotomous primary or secondary outcomes were included. FI was calculated for each RCT and its correlation with various factors was analyzed.

RESULTS

Seventy trials met inclusion criteria with a median sample size of 133 (interquartile range [IQR]: 80-218) and median reported events per trial was 38 (IQR: 13-94). The median FI score was 2 (IQR: 0-5), which means if we switch two patients from nonevent to event, the statistical significance of the outcome is lost. The FI score was less than the number of patients lost to follow-up in 28 of 70 trials. The FI score was found to positively correlated with sample size (r = 0.431, P = 0.001), total number of outcome events (r = 0.305, P = 0.01) while negatively correlated with P value (r = -0.392, P = 0.001). Funding, journal impact-factor, risk of bias domains, and year of publication did not have a significant correlation.

CONCLUSION

Statistically significant dichotomous outcomes reported in spine surgery RCTs are more often fragile and outcomes of the patients lost to follow-up could have changed the significance of results and hence it needs caution before transcending their results into clinical application. The addition of FI in routine reporting of RCTs would guide readers on the robustness of the statistical significance of outcomes. RCTs with FI ≥5 without any patient lost to follow-up can be considered to have clinically robust results.Level of Evidence: 1.

Drugs for preventing postoperative nausea and vomiting in adults after general anaesthesia: a network meta-analysis

BACKGROUND

Postoperative nausea and vomiting (PONV) is a common adverse effect of anaesthesia and surgery. Up to 80% of patients may be affected. These outcomes are a major cause of patient dissatisfaction and may lead to prolonged hospital stay and higher costs of care along with more severe complications. Many antiemetic drugs are available for prophylaxis. They have various mechanisms of action and side effects, but there is still uncertainty about which drugs are most effective with the fewest side effects.

OBJECTIVES

• To compare the efficacy and safety of different prophylactic pharmacologic interventions (antiemetic drugs) against no treatment, against placebo, or against each other (as monotherapy or combination prophylaxis) for prevention of postoperative nausea and vomiting in adults undergoing any type of surgery under general anaesthesia • To generate a clinically useful ranking of antiemetic drugs (monotherapy and combination prophylaxis) based on efficacy and safety • To identify the best dose or dose range of antiemetic drugs in terms of efficacy and safety SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP), ClinicalTrials.gov, and reference lists of relevant systematic reviews. The first search was performed in November 2017 and was updated in April 2020. In the update of the search, 39 eligible studies were found that were not included in the analysis (listed as awaiting classification).

SELECTION CRITERIA

Randomized controlled trials (RCTs) comparing effectiveness or side effects of single antiemetic drugs in any dose or combination against each other or against an inactive control in adults undergoing any type of surgery under general anaesthesia. All antiemetic drugs belonged to one of the following substance classes: 5-HT₃ receptor antagonists, D₂ receptor antagonists, NK₁ receptor antagonists, corticosteroids, antihistamines, and anticholinergics. No language restrictions were applied. Abstract publications were excluded.

DATA COLLECTION AND ANALYSIS

A review team of 11 authors independently assessed trials for inclusion and risk of bias and subsequently extracted data. We performed pair-wise meta-analyses for drugs of direct interest (amisulpride, aprepitant, casopitant, dexamethasone, dimenhydrinate, dolasetron, droperidol, fosaprepitant, granisetron, haloperidol, meclizine, methylprednisolone, metoclopramide, ondansetron, palonosetron, perphenazine, promethazine, ramosetron, rolapitant, scopolamine, and tropisetron) compared to placebo (inactive control). We performed network meta-analyses (NMAs) to estimate the relative effects and ranking (with placebo as reference) of all available single drugs and combinations. Primary outcomes were vomiting within 24 hours postoperatively, serious adverse events (SAEs), and any adverse event (AE). Secondary outcomes were drug class-specific side effects (e.g. headache), mortality, early and late vomiting, nausea, and complete response. We performed subgroup network meta-analysis with dose of drugs as a moderator variable using dose ranges based on previous consensus recommendations. We assessed certainty of evidence of NMA treatment effects for all primary outcomes and drug class-specific side effects according to GRADE (CINeMA, Confidence in Network Meta-Analysis). We restricted GRADE assessment to single drugs of direct interest compared to placebo.

MAIN RESULTS

We included 585 studies (97,516 randomized participants). Most of these studies were small (median sample size of 100); they were published between 1965 and 2017 and were primarily conducted in Asia (51%), Europe (25%), and North America (16%). Mean age of the overall population was 42 years. Most participants were women (83%), had American Society of Anesthesiologists (ASA) physical status I and II (70%), received perioperative opioids (88%), and underwent gynaecologic (32%) or gastrointestinal surgery (19%) under general anaesthesia using volatile anaesthetics (88%). In this review, 44 single drugs and 51 drug combinations were compared. Most studies investigated only single drugs (72%) and included an inactive control arm (66%). The three most investigated single drugs in this review were ondansetron (246 studies), dexamethasone (120 studies), and droperidol (97 studies). Almost all studies (89%) reported at least one efficacy outcome relevant for this review. However, only 56% reported at least one relevant safety outcome. Altogether, 157 studies (27%) were assessed as having overall low risk of bias, 101 studies (17%) overall high risk of bias, and 327 studies (56%) overall unclear risk of bias. Vomiting within 24 hours postoperatively Relative effects from NMA for vomiting within 24 hours (282 RCTs, 50,812 participants, 28 single drugs, and 36 drug combinations) suggest that 29 out of 36 drug combinations and 10 out of 28 single drugs showed a clinically important benefit (defined as the upper end of the 95% confidence interval (CI) below a risk ratio (RR) of 0.8) compared to placebo. Combinations of drugs were generally more effective than single drugs in preventing vomiting. However, single NK₁ receptor antagonists showed treatment effects similar to most of the drug combinations. High-certainty evidence suggests that the following single drugs reduce vomiting (ordered by decreasing efficacy): aprepitant (RR 0.26, 95% CI 0.18 to 0.38, high certainty, rank 3/28 of single drugs); ramosetron (RR 0.44, 95% CI 0.32 to 0.59, high certainty, rank 5/28); granisetron (RR 0.45, 95% CI 0.38 to 0.54, high certainty, rank 6/28); dexamethasone (RR 0.51, 95% CI 0.44 to 0.57, high certainty, rank 8/28); and ondansetron (RR 0.55, 95% CI 0.51 to 0.60, high certainty, rank 13/28). Moderate-certainty evidence suggests that the following single drugs probably reduce vomiting: fosaprepitant (RR 0.06, 95% CI 0.02 to 0.21, moderate certainty, rank 1/28) and droperidol (RR 0.61, 95% CI 0.54 to 0.69, moderate certainty, rank 20/28). Recommended and high doses of granisetron, dexamethasone, ondansetron, and droperidol showed clinically important benefit, but low doses showed no clinically important benefit. Aprepitant was used mainly at high doses, ramosetron at recommended doses, and fosaprepitant at doses of 150 mg (with no dose recommendation available). Frequency of SAEs Twenty-eight RCTs were included in the NMA for SAEs (10,766 participants, 13 single drugs, and eight drug combinations). The certainty of evidence for SAEs when using one of the best and most reliable anti-vomiting drugs (aprepitant, ramosetron, granisetron, dexamethasone, ondansetron, and droperidol compared to placebo) ranged from very low to low. Droperidol (RR 0.88, 95% CI 0.08 to 9.71, low certainty, rank 6/13) may reduce SAEs. We are uncertain about the effects of aprepitant (RR 1.39, 95% CI 0.26 to 7.36, very low certainty, rank 11/13), ramosetron (RR 0.89, 95% CI 0.05 to 15.74, very low certainty, rank 7/13), granisetron (RR 1.21, 95% CI 0.11 to 13.15, very low certainty, rank 10/13), dexamethasone (RR 1.16, 95% CI 0.28 to 4.85, very low certainty, rank 9/13), and ondansetron (RR 1.62, 95% CI 0.32 to 8.10, very low certainty, rank 12/13). No studies reporting SAEs were available for fosaprepitant. Frequency of any AE Sixty-one RCTs were included in the NMA for any AE (19,423 participants, 15 single drugs, and 11 drug combinations). The certainty of evidence for any AE when using one of the best and most reliable anti-vomiting drugs (aprepitant, ramosetron, granisetron, dexamethasone, ondansetron, and droperidol compared to placebo) ranged from very low to moderate. Granisetron (RR 0.92, 95% CI 0.80 to 1.05, moderate certainty, rank 7/15) probably has no or little effect on any AE. Dexamethasone (RR 0.77, 95% CI 0.55 to 1.08, low certainty, rank 2/15) and droperidol (RR 0.89, 95% CI 0.81 to 0.98, low certainty, rank 6/15) may reduce any AE. Ondansetron (RR 0.95, 95% CI 0.88 to 1.01, low certainty, rank 9/15) may have little or no effect on any AE. We are uncertain about the effects of aprepitant (RR 0.87, 95% CI 0.78 to 0.97, very low certainty, rank 3/15) and ramosetron (RR 1.00, 95% CI 0.65 to 1.54, very low certainty, rank 11/15) on any AE. No studies reporting any AE were available for fosaprepitant. Class-specific side effects For class-specific side effects (headache, constipation, wound infection, extrapyramidal symptoms, sedation, arrhythmia, and QT prolongation) of relevant substances, the certainty of evidence for the best and most reliable anti-vomiting drugs mostly ranged from very low to low. Exceptions were that ondansetron probably increases headache (RR 1.16, 95% CI 1.06 to 1.28, moderate certainty, rank 18/23) and probably reduces sedation (RR 0.87, 95% CI 0.79 to 0.96, moderate certainty, rank 5/24) compared to placebo. The latter effect is limited to recommended and high doses of ondansetron. Droperidol probably reduces headache (RR 0.76, 95% CI 0.67 to 0.86, moderate certainty, rank 5/23) compared to placebo. We have high-certainty evidence that dexamethasone (RR 1.00, 95% CI 0.91 to 1.09, high certainty, rank 16/24) has no effect on sedation compared to placebo. No studies assessed substance class-specific side effects for fosaprepitant. Direction and magnitude of network effect estimates together with level of evidence certainty are graphically summarized for all pre-defined GRADE-relevant outcomes and all drugs of direct interest compared to placebo in http://doi.org/10.5281/zenodo.4066353.

AUTHORS' CONCLUSIONS

We found high-certainty evidence that five single drugs (aprepitant, ramosetron, granisetron, dexamethasone, and ondansetron) reduce vomiting, and moderate-certainty evidence that two other single drugs (fosaprepitant and droperidol) probably reduce vomiting, compared to placebo. Four of the six substance classes (5-HT₃ receptor antagonists, D₂ receptor antagonists, NK₁ receptor antagonists, and corticosteroids) were thus represented by at least one drug with important benefit for prevention of vomiting. Combinations of drugs were generally more effective than the corresponding single drugs in preventing vomiting. NK₁ receptor antagonists were the most effective drug class and had comparable efficacy to most of the drug combinations. 5-HT₃ receptor antagonists were the best studied substance class. For most of the single drugs of direct interest, we found only very low to low certainty evidence for safety outcomes such as occurrence of SAEs, any AE, and substance class-specific side effects. Recommended and high doses of granisetron, dexamethasone, ondansetron, and droperidol were more effective than low doses for prevention of vomiting. Dose dependency of side effects was rarely found due to the limited number of studies, except for the less sedating effect of recommended and high doses of ondansetron. The results of the review are transferable mainly to patients at higher risk of nausea and vomiting (i.e. healthy women undergoing inhalational anaesthesia and receiving perioperative opioids). Overall study quality was limited, but certainty assessments of effect estimates consider this limitation. No further efficacy studies are needed as there is evidence of moderate to high certainty for seven single drugs with relevant benefit for prevention of vomiting. However, additional studies are needed to investigate potential side effects of these drugs and to examine higher-risk patient populations (e.g. individuals with diabetes and heart disease).

Intraoperative epidural application of steroid and local anaesthetic agent following lumbar discectomy: A prospective double blinded randomized controlled trial

BACKGROUND

Postoperative pain management following lumbar discectomy is a key part of the procedure and various postoperative pain protocols including a wide range of agents are being used in daily practice worldwide. The aim of this study is to investigate the effect of intraoperative epidural infiltration of local anaesthetic and steroid compared with placebo (normal saline) following microscopic lumbar discectomy.

METHODS

Sixty patients undergoing lumbar discectomy were randomized to intraoperative infiltration of 3 mg betamethoasone acetate and 18 mg ropivacaine (Group A) or normal saline (Group B). Infiltration was performed after discectomy and decompression and immediately prior to incision closure. Postoperatively a standard protocol of intravenous acetaminophen administration and physiotherapy was followed. Additional analgesia with tramadol was given only in patients who required further pain management. Postoperative pain was evaluated using VAS score. Opioid consumption was recorded. Primary outcome measures included immediate postoperative back pain VAS score, opioid consumption and infection rate. Patients were reviewed in clinic at 6 weeks, 6 months and 1 year postoperatively.

RESULTS

None of the patients in Group A required further analgesia while 12 Group B patients required further treatment with tramadol (p = 0.01). At 3 h postoperatively the VAS score was significantly lower in Group A compared to Group B (p < 0.05). Fifty-seven patients completed the 1 year follow up (95%) and 2 patients (1 from each group) suffered a complication of postoperative radiculopathy.

CONCLUSION

Intraoperative application of steroid and local anaesthetic agent is effective on pain reduction for only a short period after surgery, while there is no effect on infection rate or any other long-term outcome compared with placebo. Hence although it is a safe technique, its benefits are limited from the duration of action.

Operationalizing Multidisciplinary Assessment and Treatment as a Quality Metric for Interventional Pain Practices

Objective

Quality improvement (QI) is an underutilized approach among pain medicine specialists to improve comprehensive pain assessment and the delivery of multimodal pain care. We report the results of a QI program that utilized peer review and financial incentives to improve these processes in interventional pain clinics.

Design

Retrospective chart review.

Setting

Eight academic and community-based practices that included separate hospital-based and non-hospital-based interventional pain clinics.

Subjects

Results of chart audits by nine academic pain medicine physicians.

Methods

An audit of a random sample of each pain physician's charts was periodically examined for mention and discussion of specific components of multidisciplinary pain care. A portion of the physician's incentive payment was withheld if less than 70% of charts were compliant. The rates of compliance after the intervention for the group were compared.

Results

Before this program was instituted, an audit of 10 patient charts from each of the nine pain medicine physicians revealed only a 13% baseline rate of compliance. After the audit system was implemented, 90% of all patient charts were compliant during the first 12-month period (P < 0.01 for the change in rate of compliance).

Conclusions

The results of this QI project suggest that pain clinics can make this value-based transition and offer high-quality multidisciplinary assessment and treatment, with good compliance among a group of physicians in primarily intervention-based practices.

Effect of Steroid-Soaked Gelatin Sponge on Soft Tissue Swelling Following Anterior Cervical Discectomy and Fusion: A Radiographic Analysis

Study Design

Retrospective radiological review and analysis of 79 patients who underwent primary anterior cervical discectomy and fusion (ACDF) of 2 or 3 levels between 2011 and 2013.

Purpose

This study aimed to determine the effect of the local placement of a steroid-soaked gelatin sponge after ACDF on prevertebral soft tissue swelling.

Overview of Literature

Although ACDF has become a popular choice for cervical fusion, the surgical involvement of the delicate anatomy of the neck frequently results in tissue irritation and edema. Swelling of the prevertebral soft tissue may consequently lead to mild-to-severe complications, ranging from dysphonia to dyspnea.

Methods

Out of the 79 patients who underwent primary ACDF, 52 received a gelatin sponge soaked with 40 mg of Depo-Medrol placed adjacent to the operated cervical levels. Prevertebral soft tissue swelling was detected using postoperative lateral X-ray. The radiographic values were compared to those of 27 patients who did not receive the treatment.

Results

Soft tissue swelling was markedly decreased in patients who received the placement of the steroid-soaked gelatin sponge next to their fused levels after surgery compared with that in patients who did not receive it. No complications were documented with the use of steroids.

Conclusions

The placement of a steroid-soaked gelatin sponge markedly reduces postoperative soft tissue swelling following 2- or 3-level primary ACDF.

Comparative Outcomes of Perioperative Epidural Steroids After Percutaneous Endoscopic Lumbar Discectomy for Lumbar Disc Herniation: A Randomized Placebo-Controlled Trial

OBJECTIVE

To assess postoperative outcomes and complications after percutaneous endoscopic lumbar discectomy (PELD) with or without epidural steroids (ES) administration in lumbar disc herniation.

METHODS

In a double-blind randomized, placebo-controlled trial at Ramathibodi Hospital, Mahidol University, from May 2014 to May 2015, 30 patients were randomly allocated to receive ES or placebo (saline) after PELD. The primary outcome was 24-hour morphine consumption. Secondary outcomes were visual analog scale (VAS) scores for leg and back pain, Oswestry Disability Index score, Roland-Morris Disability Questionnaire score, and complications at 6-month follow-up.

RESULTS

Mean patient age was 60.0 years, and 0.57% of patients were male. Mean VAS back pain, VAS leg pain, Oswestry Disability Index, and Roland-Morris Disability Questionnaire scores at baseline were 4.7, 6.1, 24.9, 17.5 in the ES group and 5.1, 5.5, 24.7, 16.7 in the placebo group, respectively. Mean morphine requirements measured at 8, 16, and 24 hours were 3.47, 2.67, and <0.001 in the ES group and 3.13, 1.67, and 0.40 in the placebo group. The mean VAS scores measured at 4, 8, 12, 16, 20, and 24 hours were 2.99, 2.70, 2.56, 3.30, 3.05, and 2.05 the ES group and 3.13, 1.13, 1.26, 1.65, 1.22, and 1.08 in placebo group. The difference was not statistically significant (P > 0.05 for all).

CONCLUSIONS

Administration of ES with PELD for lumbar disc herniation does not improve postoperative pain, morphine requirements, or disability scores in the short-term and midterm periods.

Epidural versus intravenous steroids application following percutaneous endoscopic lumbar discectomy

Retrospectively study.The purpose of this study was to compare the effects of intraoperative epidural steroids and single dose intravenous steroids following a percutaneous endoscopic lumbar discectomy (PELD).Inflammatory irritation of dorsal root ganglia or sensory nerve roots may cause postoperative pain. Epidural steroids have been applied after a lumbar discectomy for more than 20 years. Epidural steroid application after a PELD is easier to perform and safer because the operations are under observation of the scope.We retrospectively reviewed the medical records of patients with lumbar intervertebral disc herniation who had undergone transforaminal PELD at our department. There are 60 patients in epidural steroid group, intravenous steroid group, and control group, respectively. Visual analog scores (VAS) and the Oswestry Disability Index (ODI) were collected. Successful pain control is defined as 50% or more reduction in back and leg pain (VAS scores).VAS scores (back and leg) and ODI showed a significant decrease in all groups when comparing pre- and postoperatively. Epidural steroid group had a significant improvement in successful pain control compared with the control group at 2 weeks of follow-up. VAS scores (leg) in the epidural steroid group showed a significant decrease compared with the intravenous steroids group at 1, 3, and 7 days after the surgery, but this difference had no statistical significance at 1, 6, and 12 months of follow-up. All groups did not show a significant difference in ODI at 1, 6, and 12 months follow-up.Epidural application of steroid has a better effect on controlling the postoperative pain of PELD in the short term. The epidural application of steroid did not show a tendency to cause infection.

Efficacy of intraoperative epidural triamcinolone application in lumbar microdiscectomy: a matched-control study

OBJECTIVE

The purpose of this study was to investigate whether the intraoperative application of an epidural steroid (ES) on the decompressed nerve root improves short- and midterm subjective and objective clinical outcomes after lumbar microdiscectomy.

METHODS

This study was a retrospective analysis of a 2-center database including consecutive cases in which patients underwent lumbar microdiscectomy. All patients who received ES application (40 mg triamcinolone, ES group) were matched by age and sex to patients who had not received ES application (control group). Objective functional impairment (OFI) was determined using age- and sex-adjusted T-scores of the Timed Up and Go (TUG) test. Back and leg pain (visual analog scale), functional impairment (Oswestry Disability Index [ODI], Roland-Morris Disability Index [RMDI], and health-related quality of life (hrQoL; 12-Item Short Form Health Survey [SF-12] physical component summary [PSC] score and EuroQol [EQ-5D index]) were measured at baseline, on postoperative day 3, and at postoperative week 6.

RESULTS

Fifty-three patients who received ES application were matched with 101 controls. There were no baseline demographic or disease-specific differences between the study groups, and preoperative pain, functional impairment, and hrQoL were similar. On postoperative day 3, the ES group had less disability on the RMDI (mean 7.4 vs 10.3, p = 0.003) and higher hrQoL as determined by the SF-12 PCS (36.5 vs 32.7, p = 0.004). At week 6, the ES group had less disability on the RMDI (3.6 vs 5.7, p = 0.050) and on the ODI by trend (17.0 vs 24.4, p = 0.056); better hrQoL, determined by the SF-12 PCS (44.3 vs 39.9, p = 0.018); and lower OFI (TUG test T-score 100.5 vs 110.2, p = 0.005). The week 6 responder status based on the minimum clinically important difference (MCID) was similar in the ES and control groups for each metric. The rates and severity of complications were similar, with a 3.8% and 4.0% reoperation rate in the ES group and control group, respectively (p = 0.272). There was a tendency for shorter hospitalization in the ES group (5.0 vs 5.8 days, p = 0.066).

CONCLUSIONS

Intraoperative ES application on the decompressed nerve root is an effective adjunct treatment that may lower subjective and objective functional impairment and increase hrQoL in the short and intermediate term after lumbar microdiscectomy. However, group differences were lower than the commonly accepted MCIDs for each metric, indicating that the effect size of the benefit is limited.

■ CLASSIFICATION OF EVIDENCE Type of question: therapeutic; study design: retrospective cohort trial; evidence: Class II.

Epidural Steroids at Closure After Microdiscectomy/Laminectomy for Reduction of Postoperative Analgesia: Systematic Review and Meta-Analysis

BACKGROUND

This review assessed the efficacy of epidural steroid administration on the reduction of pain, hospital stay time, and use of opioid analgesics postoperatively.

METHODS

We searched Medline, PubMed, Embase, Cochrane Central Register of Controlled Trials, and Cochrane Database of Systematic Reviews for studies using epidural steroids through any route after lumbar surgery. The primary study outcomes included preoperative and postoperative pain as assessed with a visual analogue scale (VAS), length of hospital stay (LOS), and postoperative use of opioid analgesics. The data were extracted and stratified according to the steroid administered. Data were then assessed for heterogeneity, subgroup differences, and ultimately tabulated in a Forest plot.

RESULTS

A total of 17 randomized controlled trials were included in this review, with 16 undergoing quantitative analysis. Steroids were shown to be superior in terms of VAS outcome at 24 hours, with triamcinolone and dexamethasone performing similarly. Methylprednisolone paradoxically performed worse at the 24-hour mark. At 1 month, all steroids illustrated superiority in terms of VAS outcome. Steroids also proved superior in reducing LOS and postoperative use of opioid analgesia.

CONCLUSIONS

Intraoperative or perioperative epidural administration of steroids offers significant benefits in terms of pain control, reduction in LOS, and use of postoperative opioid analgesia. Before steroids are routinely used by spinal surgeons, however, significantly more research is required. A particular emphasis should be placed on quality study protocols and data recording, to allow for more thorough analyses in the future.

Early rehabilitation after lumbar disc surgery is not effective or cost-effective compared to no referral: a randomised trial and economic evaluation

QUESTION

Is referral for early rehabilitation after lumbar disc surgery effective and cost-effective compared to no referral?

DESIGN

Multicentre, randomised, controlled trial, and economic evaluation with concealed allocation and intention-to-treat-analysis.

PARTICIPANTS

Adults who underwent discectomy for a herniated lumbar disc, confirmed by magnetic resonance imaging, and signs of nerve root compression corresponding to the herniation level.

INTERVENTION

Early rehabilitation (exercise therapy) for 6 to 8 weeks, versus no referral, immediately after discharge.

OUTCOME MEASURES

In line with the recommended core outcome set, the co-primary outcomes were: functional status (Oswestry Disability Index); leg and back pain (numerical rating scale 0 to 10); global perceived recovery (7-point Likert scale); and general physical and mental health (SF12), assessed 3, 6, 9, 12 and 26 weeks after surgery. The outcomes for the economic evaluation were quality of life and costs, measured at 6, 12 and 26 weeks after surgery.

RESULTS

There were no clinically relevant or statistically significant overall mean differences between rehabilitation and control for any outcome adjusted for baseline characteristics: global perceived recovery (OR 1.0, 95% CI 0.6 to 1.7), functional status (MD 1.5, 95% CI -3.6 to 6.7), leg pain (MD 0.1, 95% CI -0.7 to 0.8), back pain (MD 0.3, 95% CI -0.3 to 0.9), physical health (MD -3.5, 95% CI -11.3 to 4.3), and mental health (MD -4.1, 95% CI -9.4 to 1.3). After 26 weeks, there were no significant differences in quality-adjusted life years (MD 0.01, 95% CI -0.02 to 0.04 points) and societal costs (MD -€527, 95% CI -2846 to 1506). The maximum probability for the intervention to be cost-effective was 0.75 at a willingness-to-pay of €32 000/quality-adjusted life year.

CONCLUSION

Early rehabilitation after lumbar disc surgery was neither more effective nor more cost-effective than no referral.

TRIAL REGISTRATION

Netherlands Trial Register NTR3156. [Oosterhuis T, Ostelo RW, van Dongen JM, Peul WC, de Boer MR, Bosmans JE, Vleggeert-Lankamp CL, Arts MP, van Tulder MW (2017) Early rehabilitation after lumbar disc surgery is not effective or cost-effective compared to no referral: a randomised trial and economic evaluation. Journal of Physiotherapy 63: 144-153].

Perioperative steroids for lumbar disc surgery: A meta-analysis of randomized controlled trials

BACKGROUND

Our review question was "Does perioperative steroids administration, in comparison with other treatments or placebo, improve either postoperative pain control, length of hospital stay, or return to work in patients undergoing lumbar disc surgery?"

METHODS

We searched PubMed, CINAHL PLUS, and Cochrane databases for randomized control trials (RCTs) studying the role of steroids for lumbar disc surgery. Studies that compared perioperative steroids with other treatments or placebo were included. Study outcomes included postoperative back pain, leg pain, length of hospital stay, and return to work. Data was extracted through a proforma. Means and mean differences were calculated for continuous data, whereas odds ratios were calculated for dichotomous data. Data were analyzed with the help of Rev Man 5.

RESULTS

Twenty RCTs were included in the review. Quantitative analysis could be performed on 19 RCTs. Intraoperative steroids improve control of back pain at 24-48 hours. Although there was some benefit of steroid administration in controlling postoperative leg pain, it disappeared at 1 year and in the overall pooled analysis. The length of hospital stay was much shorter in the steroid group. The frequency of adverse events and complications also favored steroid administration.

CONCLUSION

Intraoperative epidural steroid administration offers some benefit in pain control with a significant reduction in the length of hospital stay. However, there is insufficient evidence to support the routine use of oral and intravenous steroids in the perioperative period.

The Role of Multimodal Analgesia in Spine Surgery

Optimal postoperative pain control allows for faster recovery, reduced complications, and improved patient satisfaction. Historically, pain management after spine surgery relied heavily on opioid medications. Multimodal regimens were developed to reduce opioid consumption and associated adverse effects. Multimodal approaches used in orthopaedic surgery of the lower extremity, especially joint arthroplasty, have been well described and studies have shown reduced opioid consumption, improved pain and function, and decreased length of stay. A growing body of evidence supports multimodal analgesia in spine surgery. Methods include the use of preemptive analgesia, NSAIDs, the neuromodulatory agents gabapentin and pregabalin, acetaminophen, and extended-action local anesthesia. The development of a standard approach to multimodal analgesia in spine surgery requires extensive assessment of the literature. Because a substantial number of spine surgeries are performed annually, a standardized approach to multimodal analgesia may provide considerable benefits, particularly in the context of the increased emphasis on accountability within the healthcare system.

Intraregional differences of perioperative management strategy for lumbar disc herniation: is the Devil really in the details?

BACKGROUND

This study intends to evaluate whether regional common habits or differences in case-volume between surgeons are significative variables in the perioperative management of patients undergoing surgery for lumbar disc herniation.

METHODS

An e-mail survey was sent to all neurosurgeons working in Lombardy, Italy's most populated region. The survey consisted of 17 questions about the perioperative management of lumbar disc herniation.

RESULTS

Forty-seven percent (47%) out of 206 Lombard neurosurgeons answered the survey. Although in some respects there is clear evidence in current literature on which is the best practice to adopt for an optimal management strategy, we noticed substantial differences between respondents, not only between hospitals but also between surgeons from the same hospital. Still, no differences were evident in a high vs low case-volume comparison.

CONCLUSION

We identified no regional clusterization as for practical principles in the perioperative management of lumbar disc herniation and neither was case-volume a significative variable. Other causes may be relevant in the variability between the perioperative management and the outcomes achieved by different specialists.

Complications of intraoperative epidural steroid use in lumbar discectomy: a systematic review and meta-analysis

OBJECT The authors' aim in this paper was to review the intraoperative use of epidural steroids in lumbar discectomy surgery with a focus on surgical complications. METHODS A comprehensive literature search was done using PubMed, MEDLINE, and the Cochrane Central Registry of Controlled Trials. Relevant papers were retrieved and analyzed. The authors performed a meta-analysis of all available data. Search terms included epidural, steroids, discectomy, lumbar disc surgery, herniated lumbar disc, methylprednisolone, and perioperative.The primary outcome was surgical complications such as wound infection or need for reoperation. Secondary outcomes were pain and postoperative narcotic usage. RESULTS Sixteen trials and 1 retrospective study (a total of 1933 patients) were eligible for inclusion in this study. In all studies, steroids were added epidurally over the nerve root before closure in cases, and control patients underwent discectomy alone. The mean age (42.7 years vs 42.4 years; RR 0.30 [95% CI -0.30 to 0.90], p = 0.32), overall complication rates (2.69% vs 1.18%; RR 1.94 [95% CI 0.72-5.26], p = 0.19), and infectious complication rates (0.94% vs 0.08%; RR 4.58 [95% CI 0.75-27.95], p = 0.10) were similar between the steroid group and control group, respectively. CONCLUSIONS There is good evidence that epidural steroids can decrease pain in the short term and decrease the usage of postoperative narcotics after lumbar spinal surgery for degenerative spinal disease. The authors' results demonstrate a trend toward increased infection with epidural steroid use, but there was not a statistically significant difference. More studies are needed to validate the long-term risk/benefit ratio of epidural steroids in lumbar discectomy.

Epidural steroids for spinal pain and radiculopathy: a narrative, evidence-based review

PURPOSE OF REVIEW

Epidural steroid injections (ESIs) are the most commonly performed intervention in pain clinics across the USA and worldwide. In light of the growing use of ESIs, a recent spate of highly publicized infectious complications, and increasing emphasis on cost-effectiveness, the utility of ESI has recently come under intense scrutiny. This article provides an evidence-based review of ESIs, including the most up-to-date information on patient selection, comparison of techniques, efficacy, and complications.

RECENT FINDINGS

The data strongly suggest that ESIs can provide short-term relief of radicular symptoms but are less convincing for long-term relief, and mixed regarding cost-effectiveness. Although some assert that transforaminal ESIs are more efficacious than interlaminar ESIs, and that fluoroscopy can improve treatment outcomes, the evidence to support these assertions is limited.

SUMMARY

The cost-effectiveness of ESI is the subject of great debate, and similar to efficacy, the conclusions one draws appear to be influenced by specialty. Because of the wide disparities regarding indications and utilization, it is likely that indiscriminate use is cost-ineffective, but that judicious use in well-selected patients can decrease healthcare utilization. More research is needed to better refine selection criteria for ESI, and to determine which approach, what dose, and how many injections are optimal.

Preoperative epidural injections are associated with increased risk of infection after single-level lumbar decompression

BACKGROUND CONTEXT

Lumbar epidural steroid injections (LESIs) are often performed as a treatment option for lumbar stenosis and radiculopathy before lumbar decompression surgery. Several case series have reported spinal infections after LESIs. There is lack of literature on the rate of postoperative infections after lumbar decompression in patients who had prior LESIs.

PURPOSE

The goal of the present study is to employ a large national database to determine if there is an association between preoperative LESIs at various time intervals before lumbar decompression and the incidence of postoperative infection.

STUDY DESIGN/SETTING

Retrospective case control database study, Level III was used in this study.

PATIENT SAMPLE

This study comprised Medicare patients over age 65 years who had a LESI within 1 year of single-level lumbar decompression surgery.

OUTCOME MEASURES

International Classification of Diseases, 9th Revision diagnosis codes for postoperative infection and Current Procedural Terminology procedure codes for treatment of postoperative infection were the outcome measures for this study.

METHODS

The PearlDiver Patient Records Database, an insurance-based database of patient records, was used for this study. The database was queried for LESI and single-level lumbar decompression procedures using Current Procedural Terminology codes. These study patients were then divided into four separate cohorts: (1) lumbar decompression within 1 month following LESI, (2) lumbar decompression between 1 and 3 months following LESI, (3) lumbar decompression between 3 and 6 months following LESI, and (4) lumbar decompression between 6 and 12 months following LESI. Unique control groups for each study cohort were created with patients who underwent single-level lumbar decompression without previous LESI and matched for major risk factors for infection, including age, gender, smoking status, diabetes, and obesity.

RESULTS

Overall, the rate of postoperative infection after single-level lumbar decompression after LESI remained relatively low, ranging between 0.8% and 1.7%. The incidence of 90-day postoperative infection after lumbar decompression was significantly higher than matched controls in groups with LESI within 1 month (OR=3.2, p<.0001) and 1-3 months before surgery (OR=1.8, p<.0001). The incidence of 90-day postoperative infection was not significantly different from matched controls in groups with LESI between 3-6 months (OR=1.3, p=.15) and 6-12 months before decompression surgery (OR=1.3, p=.18) CONCLUSIONS: Single-level lumbar decompression within 3 months after LESI may be associated with an increased rate of postoperative infection. Increasing the time interval between LESI and single-level lumbar decompression surgery to at least 3 months may decrease postoperative infection rates.

Delayed esophageal perforation after anterior cervical fusion and retropharyngeal steroid use: a report of two cases

BACKGROUND CONTEXT

Prevertebral soft-tissue swelling (PSTS) after anterior cervical spine surgery may result in postoperative catastrophic airway complications and persistent dysphagia. Systemic or local corticosteroids have been used to decrease complications related to PSTS. To date, studies using retropharyngeal steroid (RS) have not reported complications with local steroids such as infection, pseudarthrosis, and other systemic adverse effects.

PURPOSE

The aim was to report delayed esophageal perforation in two patients who underwent anterior cervical spine surgery and RS use.

STUDY DESIGN/SETTING

This was a case report with a review of literature.

METHODS

We presented two cases of delayed esophageal perforation without obvious cause in two patients who underwent anterior cervical spine surgery and RS use.

RESULTS

A 45-year-old woman underwent C5-C6 anterior cervical discectomy and fusion (ACDF) for radiculopathy. Just before closing the wound, one ampule of triamcinolone acetate was placed in the retropharyngeal space. Two months postoperatively, she presented to the emergency department with clinical symptoms of esophageal perforation. Radiographic studies demonstrated a retropharyngeal abscess. A 0.5×1.0-cm sized esophageal defect was identified during the emergency surgery. Complete healing of the esophageal defect was achieved by revision repair with reinforcement using local muscle flap. A 65-year-old man with a history of ankylosing spondylitis presented with severe dysphagia 1 year after C7 pedicle subtraction osteotomy, C2-T4 posterior instrumentation, and C6-C7 ACDF with a plate for a chin-on-chest deformity. Before closure, 1 cc of depomedrol had been placed into the wound. Eleven months postoperatively, he complained of new onset dysphagia. The endoscopic examination demonstrated an esophageal tear with visualization of the anterior cervical plate through the tear. Successful healing was possible with primary repair.

CONCLUSIONS

Retropharyngeal steroids have been shown to decrease PSTS and dysphagia after anterior cervical spine surgery. We believe that it would be prudent to consider avoiding the RS use in patients with a history of chronic corticosteroid use and/or soft-tissue vulnerability or only to use them with caution. Any history of dysphagia that occurs weeks, months, or even years later should be investigated for the possibility of esophageal perforation.

Epidural Steroids After a Percutaneous Endoscopic Lumbar Discectomy

STUDY DESIGN

Randomized controlled study from a single surgeon.

OBJECTIVE

The objective of the present study is to assess the effectiveness of the administration of epidural steroids in patients who undergo a percutaneous endoscopic lumbar discectomy (PELD) because of a herniated lumbar disc.

SUMMARY OF BACKGROUND DATA

Steroids are drugs that show strong anti-inflammatory effects; in specific, the effects of epidural steroid application after an open lumbar discectomy have been studied extensively. However, no study has been conducted on the effects of perioperative epidural steroids after PELD.

METHODS

One hundred patients who had undergone a PELD because of a herniated lumbar disc were randomized into 2 groups. Patients in group 1 were subjected to an epidural steroid application after a PELD, whereas patients in group 2 were treated with saline after a PELD.

RESULTS

There was a significant decrease in visual analogue scale (VAS) scores (back, leg) and Oswestry Disability Index at all examinations (P < 0.01). When comparing the 2 groups, group 1 showed lower levels of VAS scores (back) in all examinations than group 2 but was not statistically significant (P = 0.257). In VAS score (leg), group 1 showed a significant decrease compared with the group 2 at 1 and 4 weeks of follow-up examination (P = 0.020, P = 0.032). In Oswestry Disability Index, group 1 showed a significant decrease compared with the group 2 at 1-week follow-up examination (P < 0.01).The mean hospital stay was statistically significantly shorter in group 1 (P < 0.01). The mean periods before returning to work for those who returned to work in group 1 and group 2 were 4.45 ± 3.59 weeks and 6.48 ± 4.88 weeks, respectively, when measured at follow-up at 6 months; the period in group 1 was statistically significantly shorter (P = 0.024).

CONCLUSION

Epidural steroids after a PELD reduce back pain and leg pain while improving functional outcomes in the short-term postsurgery period.

LEVEL OF EVIDENCE

2.

Comparative clinical effectiveness of management strategies for sciatica: systematic review and network meta-analyses

BACKGROUND

There are numerous treatment approaches for sciatica. Previous systematic reviews have not compared all these strategies together.

PURPOSE

To compare the clinical effectiveness of different treatment strategies for sciatica simultaneously.

STUDY DESIGN

Systematic review and network meta-analysis.

METHODS

We searched 28 electronic databases and online trial registries, along with bibliographies of previous reviews for comparative studies evaluating any intervention to treat sciatica in adults, with outcome data on global effect or pain intensity. Network meta-analysis methods were used to simultaneously compare all treatment strategies and allow indirect comparisons of treatments between studies. The study was funded by the UK National Institute for Health Research Health Technology Assessment program; there are no potential conflict of interests.

RESULTS

We identified 122 relevant studies; 90 were randomized controlled trials (RCTs) or quasi-RCTs. Interventions were grouped into 21 treatment strategies. Internal and external validity of included studies was very low. For overall recovery as the outcome, compared with inactive control or conventional care, there was a statistically significant improvement following disc surgery, epidural injections, nonopioid analgesia, manipulation, and acupuncture. Traction, percutaneous discectomy, and exercise therapy were significantly inferior to epidural injections or surgery. For pain as the outcome, epidural injections and biological agents were significantly better than inactive control, but similar findings for disc surgery were not statistically significant. Biological agents were significantly better for pain reduction than bed rest, nonopioids, and opioids. Opioids, education/advice alone, bed rest, and percutaneous discectomy were inferior to most other treatment strategies; although these findings represented large effects, they were statistically equivocal.

CONCLUSIONS

For the first time, many different treatment strategies for sciatica have been compared in the same systematic review and meta-analysis. This approach has provided new data to assist shared decision-making. The findings support the effectiveness of nonopioid medication, epidural injections, and disc surgery. They also suggest that spinal manipulation, acupuncture, and experimental treatments, such as anti-inflammatory biological agents, may be considered. The findings do not provide support for the effectiveness of opioid analgesia, bed rest, exercise therapy, education/advice (when used alone), percutaneous discectomy, or traction. The issue of how best to estimate the effectiveness of treatment approaches according to their order within a sequential treatment pathway remains an important challenge.

Do Epidural Injections Provide Short- and Long-term Relief for Lumbar Disc Herniation? A Systematic Review

BACKGROUND

As part of a comprehensive nonsurgical approach, epidural injections often are used in the management of lumbar disc herniation. Recent guidelines and systematic reviews have reached different conclusions about the efficacy of epidural injections in managing lumbar disc herniation.

QUESTIONS/PURPOSES

In this systematic review, we determined the efficacy (pain relief and functional improvement) of the three anatomic approaches (caudal, lumbar interlaminar, and transforaminal) for epidural injections in the treatment of disc herniation.

METHODS

We performed a literature search from 1966 to June 2013 in PubMed, Cochrane library, US National Guideline Clearinghouse, previous systematic reviews, and cross-references for trials studying all types of epidural injections in managing chronic or chronic and subacute lumbar disc herniation. We wanted only randomized controlled trials (RCTs) (either placebo or active controlled) to be included in our analysis, and 66 studies found in our search fulfilled these criteria. We then assessed the methodologic quality of these 66 studies using the Cochrane review criteria for RCTs. Thirty-nine studies were excluded, leaving 23 RCTs of high and moderate methodologic quality for analysis. Evidence for the efficacy of all three approaches for epidural injection under fluoroscopy was strong for short-term (< 6 months) and moderate for long-term (≥ 6 months) based on the Cochrane rating system with five levels of evidence (best evidence synthesis), with strong evidence denoting consistent findings among multiple high-quality RCTs and moderate evidence denoting consistent findings among multiple low-quality RCTs or one high-quality RCT. The primary outcome measure was pain relief, defined as at least 50% improvement in pain or 3-point improvement in pain scores in at least 50% of the patients. The secondary outcome measure was functional improvement, defined as 50% reduction in disability or 30% reduction in the disability scores.

RESULTS

Based on strong evidence for short-term efficacy from multiple high-quality trials and moderate evidence for long-term efficacy from at least one high quality trial, we found that fluoroscopic caudal, lumbar interlaminar, and transforaminal epidural injections were efficacious at managing lumbar disc herniation in terms of pain relief and functional improvement.

CONCLUSIONS

The available evidence suggests that epidural injections performed under fluoroscopy by trained physicians offer improvement in pain and function in well-selected patients with lumbar disc herniation.

Epidural injections in prevention of surgery for spinal pain: systematic review and meta-analysis of randomized controlled trials

BACKGROUND CONTEXT

Low back pain is debilitating and costly, especially for patients not responding to conservative therapy and requiring surgery.

PURPOSE

Our objective was to determine whether epidural steroid injections (ESI) have a surgery-sparing effect in patients with spinal pain.

STUDY DESIGN/SETTING

The study design was based on a systematic review and meta-analysis.

METHODS

Databases searched included Cochrane, PubMed, and EMBASE. The primary analysis evaluated randomized controlled trials (RCTs) in which treatment groups received ESI and control groups underwent control injections. Secondary analyses involved RCTs comparing surgery with ESI, and subgroup analyses of trials comparing surgery with conservative treatment in which the operative disposition of subjects who received ESI were evaluated.

RESULTS

Of the 26 total studies included, only those evaluating the effect of ESI on the need for surgery as a primary outcome examined the same patient cohort, providing moderate evidence that patients who received ESI were less likely to undergo surgery than those who received control treatment. For studies examining surgery as a secondary outcome, ESI demonstrated a trend to reduce the need for surgery for short-term (<1 year) outcomes (risk ratio, 0.68; 95% confidence interval, 0.41-1.13; p=.14) but not long-term (≥1 year) outcomes (0.95, 0.77-1.19, p=.68). Secondary analyses provided low-level evidence suggesting that between one-third and half of patients considering surgery who undergo ESI can avoid surgery.

CONCLUSIONS

Epidural steroid injections may provide a small surgery-sparing effect in the short term compared with control injections and reduce the need for surgery in some patients who would otherwise proceed to surgery.

Analgesia after Epidural Dexamethasone is Further Enhanced by IV Dipyrone, but Not IV Parecoxibe Following Minor Orthopedic Surgery

Background

Epidural administration of dexamethasone has been suggested for pain control after minor orthopedic surgery. This study was conducted to assess its efficacy after such surgery, combined or not to IV dipyrone, IV parecoxibe or their combination.

Methods

91 patients were randomly assigned to seven groups. Patients were submitted to spinal bupivacaine anesthesia combined to epidural administration of either 10 ml saline or 10 mg dexamethasone diluted to 10-ml volume. Patients also received 10 ml IV saline or 1 gr dipyrone and/or 40 mg parecoxibe diluted to 10 ml with saline. Control group (CG) received epidural and IV saline. Dexamethasone group (DexG) received epidural dexamethasone and IV saline. Dipyrone group (DipG) received epidural saline and IV dipyrone. Dex-Dip G received epidural dexamethasone and IV dipyrone. Parecoxibe group (ParG) received epidural saline and IV parecoxibe. Dex-ParG received epidural dexamethasone and IV parecoxibe. Finally, Dex-Dip-ParG received epidural dexamethasone and IV dipyrone plus IV parecoxibe.

Results

The CG expressed 4h of analgesia and sooner requested pain killer. DexG was similar to DipG or ParG or Dex-ParG (7-hours), and they requested less ketoprofen compared to the CG (P < 0.05). However, the Dex-DipG and the Dex-Dip-ParG resulted in longer time to demand pain killer (17-hours) and less ketoprofen consumption in 24-hours (P < 0.002). Adverse effects were similar among groups.

Conclusions

The analgesia secondary to epidural dexamethasone was enhanced by IV dipyrone, while no effects were observed by the addition of IV parecoxibe.

Efficacy of intraoperative epidural steroids in lumbar discectomy: a systematic review

BACKGROUND

This study is a descriptive review of the literature aimed at examining the efficacy of the use of intraoperative epidural steroids in lumbar disc surgery, a matter that remains controversial.

METHODS

The relevant clinical trials were selected from databases and reviewed. The methodological quality of each included study was assessed and graded for perceived risk of bias. All the documented significant and non-significant findings were collected. Our outcome targets were reduction in postoperative pain scores, consumption of analgesia, duration of hospital stay and no increase in complication rates. The variation in the timing of postoperative pain assessments necessitated grouping the outcome into three postoperative stages; early: 0 to 2 weeks, intermediate: more than 2 weeks to 2 months and late: more than 2 months to 1 year.

RESULTS

Sixteen trials that were published from 1990 to 2012 were eligible. At least one significant reduction in pain score was reported in nine of the eleven trials that examined pain in the early stage, in four of the seven trials that examined pain in the intermediate stage and in two of the eight trials that examined pain in the late stage. Seven of the nine trials that looked at consumption of postoperative analgesia reported significant reduction while six of the ten trails that examined the duration of hospital stay reported significant reduction. None of the trials reported a significant increase of steroid-related complications.

CONCLUSIONS

There is relatively strong evidence that intraoperative epidural steroids are effective in reducing pain in the early stage and reducing consumption of analgesia. There is also relatively strong evidence that they are ineffective in reducing pain in the late stage and in reducing duration of hospital stay. The evidence for their effectiveness in reducing pain in the intermediate stage is considered relatively weak. The heterogeneity between the trials makes it difficult to make undisputed conclusions and it indicates the need for a large multicenter trial with validated outcome measures that are recorded at fixed time intervals.

Rehabilitation after lumbar disc surgery

BACKGROUND

Several rehabilitation programmes are available for individuals after lumbar disc surgery.

OBJECTIVES

To determine whether active rehabilitation after lumbar disc surgery is more effective than no treatment, and to describe which type of active rehabilitation is most effective. This is the second update of a Cochrane Review first published in 2002.First, we clustered treatments according to the start of treatment.1. Active rehabilitation that starts immediately postsurgery.2. Active rehabilitation that starts four to six weeks postsurgery.3. Active rehabilitation that starts longer than 12 months postsurgery.For every cluster, the following comparisons were investigated.A. Active rehabilitation versus no treatment, placebo or waiting list control.B. Active rehabilitation versus other kinds of active rehabilitation.C. Specific intervention in addition to active rehabilitation versus active rehabilitation alone.

SEARCH METHODS

We searched CENTRAL (2013, Issue 4) and MEDLINE, EMBASE, CINAHL, PEDro and PsycINFO to May 2013.

SELECTION CRITERIA

We included only randomised controlled trials (RCTs).

DATA COLLECTION AND ANALYSIS

Pairs of review authors independently assessed studies for eligibility and risk of bias. Meta-analyses were performed if studies were clinically homogeneous. The GRADE approach was used to determine the overall quality of evidence.

MAIN RESULTS

In this update, we identified eight new studies, thereby including a total of 22 trials (2503 participants), 10 of which had a low risk of bias. Most rehabilitation programmes were assessed in only one study. Both men and women were included, and overall mean age was 41.4 years. All participants had received standard discectomy, microdiscectomy and in one study standard laminectomy and (micro)discectomy. Mean duration of the rehabilitation intervention was 12 weeks; eight studies assessed six to eight-week exercise programmes, and eight studies assessed 12 to 13-week exercise programmes. Programmes were provided in primary and secondary care facilities and were started immediately after surgery (n = 4) or four to six weeks (n = 16) or one year after surgery (n = 2). In general, the overall quality of the evidence is low to very low. Rehabilitation programmes that started immediately after surgery were not more effective than their control interventions, which included exercise. Low- to very low-quality evidence suggests that there were no differences between specific rehabilitation programmes (multidisciplinary care, behavioural graded activity, strength and stretching) that started four to six weeks postsurgery and their comparators, which included some form of exercise. Low-quality evidence shows that physiotherapy from four to six weeks postsurgery onward led to better function than no treatment or education only, and that multidisciplinary rehabilitation co-ordinated by medical advisors led to faster return to work than usual care. Statistical pooling was performed only for three comparisons in which the rehabilitation programmes started four to six weeks postsurgery: exercise programmes versus no treatment, high- versus low-intensity exercise programmes and supervised versus home exercise programmes. Very low-quality evidence (five RCTs, N = 272) shows that exercises are more effective than no treatment for pain at short-term follow-up (standard mean difference (SMD) -0.90; 95% confidence interval (CI) -1.55 to -0.24), and low-quality evidence (four RCTs, N = 252) suggests that exercises are more effective for functional status on short-term follow-up (SMD -0.67; 95% CI -1.22 to -0.12) and that no difference in functional status was noted on long-term follow-up (three RCTs, N = 226; SMD -0.22; 95% CI -0.49 to 0.04). None of these studies reported that exercise increased the reoperation rate. Very low-quality evidence (two RCTs, N = 103) shows that high-intensity exercise programmes are more effective than low-intensity exercise programmes for pain in the short term (weighted mean difference (WMD) -10.67; 95% CI -17.04 to -4.30), and low-quality evidence (two RCTs, N = 103) shows that they are more effective for functional status in the short term (SMD -0.77; 95% CI -1.17 to -0.36). Very low-quality evidence (four RCTs, N = 154) suggests no significant differences between supervised and home exercise programmes for short-term pain relief (SMD -0.76;  95% CI -2.04 to 0.53) or functional status (four RCTs, N = 154; SMD -0.36; 95% CI -0.88 to 0.15).

AUTHORS' CONCLUSIONS

Considerable variation was noted in the content, duration and intensity of the rehabilitation programmes included in this review, and for none of them was high- or moderate-quality evidence identified. Exercise programmes starting four to six weeks postsurgery seem to lead to a faster decrease in pain and disability than no treatment, with small to medium effect sizes, and high-intensity exercise programmes seem to lead to a slightly faster decrease in pain and disability than is seen with low-intensity programmes, but the overall quality of the evidence is only low to very low. No significant differences were noted between supervised and home exercise programmes for pain relief, disability or global perceived effect. None of the trials reported an increase in reoperation rate after first-time lumbar surgery. High-quality randomised controlled trials are strongly needed.

Effects of releasing recombinant human growth and differentiation factor-5 from poly(lactic-co-glycolic acid) microspheres for repair of the rat degenerated intervertebral disc

Purpose:

The objective of this study was to investigate the therapeutic potential of poly(lactic- co-glycolic acid) (PLGA) microspheres loaded with recombinant human growth and differentiation factor-5 (rhGDF-5) on the disc degeneration induced by needle puncture in a rat caudal disc model.

Methods:

The rhGDF-5-loaded PLGA microspheres were prepared by the water-oil-water double-emulsion solvent evaporation method, and release kinetics was determined over 42 days. Rats that underwent 21-G needle puncture at rat tail discs were injected with rhGDF-5/PLGA microspheres at four weeks after needle injury. At eight weeks after the injection, disc height, glycosaminoglycans content, and DNA content of the discs were evaluated. In addition, gene expression analysis of aggrecan, collagen type I, and collagen type II in the rat nucleus pulposus was measured by real-time polymerase chain reaction. Rat discs were also assessed by histology using hematoxylin and eosin stain.

Results:

Encapsulation of rhGDF-5 in PLGA microspheres guaranteed a sustained release of active rhGDF-5 for more than 42 days. The injection of GDF-5/PLGA microspheres resulted in a statistically significant restoration of disc height ( p < 0.01), improvement of sulfated glycosaminoglycan ( p < 0.05), DNA content ( p < 0.05), and significantly increased mRNA levels of collagen type II ( p < 0.01), and the differentiation index (the ratio of collagen type II to collagen type I, p < 0.01). In addition, rhGDF-5/PLGA microspheres treatment also improved histological changes induced by needle puncture.

Conclusions:

The results of this study suggest that injection of rhGDF-5 loaded in PLGA microspheres into rat tail discs may be as a promising therapy strategy to regenerate or repair the degenerative disc.

Epidural steroids: a comprehensive, evidence-based review

Epidural steroid injections (ESIs) are the most widely utilized pain management procedure in the world, their use supported by more than 45 placebo-controlled studies and dozens of systematic reviews. Despite the extensive literature on the subject, there continues to be considerable controversy surrounding their safety and efficacy. The results of clinical trials and review articles are heavily influenced by specialty, with those done by interventional pain physicians more likely to yield positive findings. Overall, more than half of controlled studies have demonstrated positive findings, suggesting a modest effect size lasting less than 3 months in well-selected individuals. Transforaminal injections are more likely to yield positive results than interlaminar or caudal injections, and subgroup analyses indicate a slightly greater likelihood for a positive response for lumbar herniated disk, compared with spinal stenosis or axial spinal pain. Other factors that may increase the likelihood of a positive outcome in clinical trials include the use of a nonepidural (eg, intramuscular) control group, higher volumes in the treatment group, and the use of depo-steroid. Serious complications are rare following ESIs, provided proper precautions are taken. Although there are no clinical trials comparing different numbers of injections, guidelines suggest that the number of injections should be tailored to individual response, rather than a set series. Most subgroup analyses of controlled studies show no difference in surgical rates between ESI and control patients; however, randomized studies conducted by spine surgeons, in surgically amenable patients with standardized operative criteria, indicate that in some patients the strategic use of ESI may prevent surgery.

Day case lumbar discectomy--viable option in the UK?

INTRODUCTION

The inpatient length of stay for lumbar discectomy has been steadily declining, since its original description over 80 years ago. The operation was first described as a day case procedure in 1987, but only sporadically since then, especially in the UK. We describe our initial experience in introducing this service in Manchester.

METHODS

Over a 2-year period, 50 of 80 patients undergoing lumbar discectomy met the inclusion criteria for day case surgery, using standard microscopic techniques and admission via a day case unit.

RESULTS

Majority (N = 48) were single level, unilateral discectomies and 36 (72%) were discharged home the same day. The remainder (28%) were discharged after an overnight stay and within 24 h. Reasons for this included post-operative back pain and hypotension. Majority (N = 47), reported improvement or resolution of pre-operative back and leg pain, which was quantified using Visual analogue scores (p < 0.01).

CONCLUSIONS

Lumbar microdiscectomy as a day case procedure remains a feasible and safe option in selected patients and can help free up in patient beds with a significant economic benefit also.

A comprehensive multimodal pain treatment reduces opioid consumption after multilevel spine surgery

PURPOSE

Major spine surgery with multilevel instrumentation is followed by large amount of opioid consumption, significant pain and difficult mobilization in a population of predominantly chronic pain patients. This case-control study investigated if a standardized comprehensive pain and postoperative nausea and vomiting (PONV) treatment protocol would improve pain treatment in this population.

METHODS

A new regimen with acetaminophen, NSAIDs, gabapentin, S-ketamine, dexamethasone, ondansetron and epidural local anesthetic infusion or patient controlled analgesia with morphine, was introduced in a post-intervention group of 41 consecutive patients undergoing multilevel (median 10) instrumented spinal fusions and compared with 44 patients in a pre-intervention group.

RESULTS

Compared to patients in the pre-intervention group, patients treated according to the new protocol consumed less opioid on postoperative day (POD) 1 (P = 0.024) and 2 (P = 0.048), they were mobilized earlier from bed (P = 0.003) and ambulation was earlier both with and without a walking frame (P = 0.027 and P = 0.027, respectively). Finally, patients following the new protocol experienced low intensities of nausea, sedation and dizziness on POD 1-6.

CONCLUSIONS

In this study of patients scheduled for multilevel spine surgery, it was demonstrated that compared to a historic group of patients receiving usual care, a comprehensive and standardized multimodal pain and PONV protocol significantly reduced opioid consumption, improved postoperative mobilization and presented concomitant low levels of nausea, sedation and dizziness.

Effects of sodium hyaluronate and methylprednisolone alone or in combination in preventing epidural fibrosis

OBJECTIVE

Epidural fibrosis and leptomeningeal adhesion formation are common causes of failed back surgery syndrome (FBSS). We employed a rat model of lumbar laminectomy to evaluate the histopathological effects of sodium hyaluronate (HA) and methylprednisolone (MP) alone or in combination on post-laminectomy epidural fibrosis.

METHODS

Thirty-two male Sprague-Dawley rats were divided into four groups. All rats underwent three-level lumbar laminectomy. In the treatment groups, HA solution, MP, or a combination of both was applied locally to the epidural spaces of the laminectomy fields. No neurological deficits or pathological wound site changes were observed in any of the groups. At the end of the sixth week, all rats were sacrificed, and the laminectomy vertebral column areas were removed en-bloc. Specimens were evaluated by an expert neuropathologist according to histopathological criteria.

RESULTS

The results of the three treatment groups were separately compared with the control group to assess epidural fibrosis. Minimal reduction in the rate of epidural fibrosis was observed in the groups treated with HA or MP compared with the control group. However, no significant difference in epidural fibrosis was noted between the combined treatment group and the control group.

CONCLUSIONS

Our study showed that MP and HA, given separately, significantly reduce post-laminectomy epidural fibrosis; however, the combination of these drugs is not effective. Further investigation is needed to address the causative drug interactions.

Effectiveness and cost-effectiveness of rehabilitation after lumbar disc surgery (REALISE): design of a randomised controlled trial

Background

Patients who undergo lumbar disc surgery for herniated discs, are advocated two different postoperative management strategies: a watchful waiting policy, or referral for rehabilitation immediately after discharge from the hospital. A direct comparison of the effectiveness and cost-effectiveness of these two strategies is lacking.

Methods/Design

A randomised controlled trial will be conducted with an economic evaluation alongside to assess the (cost-) effectiveness of rehabilitation after lumbar disc surgery. Two hundred patients aged 18–70 years with a clear indication for lumbar disc surgery of a single level herniated disc will be recruited and randomly assigned to either a watchful waiting policy for first six weeks or exercise therapy starting immediately after discharge from the hospital. Exercise therapy will focus on resumption of activities of daily living and return to work. Therapists will tailor the intervention to the individual patient’s needs. All patients will be followed up by the neurosurgeon six weeks postoperatively. Main outcome measures are: functional status, pain intensity and global perceived recovery. Questionnaires will be completed preoperatively and at 3, 6, 9, 12 and 26 weeks after surgery. Data will be analysed according to the intention-to-treat principle, using a linear mixed model for continuous outcomes and a generalised mixed model for dichotomous outcomes. The economic evaluation will be performed from a societal perspective.

Discussion

The results of this trial may lead to a more consistent postoperative strategy for patients who will undergo lumbar disc surgery.

Trial registration

Netherlands Trial Register: NTR3156

The impact of epidural steroid injections on the outcomes of patients treated for lumbar disc herniation: a subgroup analysis of the SPORT trial

BACKGROUND

The Spine Patient Outcomes Research Trial (SPORT) is a prospective, multicenter study of operative versus nonoperative treatment of lumbar intervertebral disc herniation. It has been suggested that epidural steroid injections may help improve patient outcomes and lower the rate of crossover to surgical treatment.

METHODS

One hundred and fifty-four patients included in the intervertebral disc herniation arm of the SPORT who had received an epidural steroid injection during the first three months of the study and no injection prior to the study (the ESI group) were compared with 453 patients who had not received an injection during the first three months of the study or prior to the study (the No-ESI group).

RESULTS

There was a significant difference in the preference for surgery between groups (19% in the ESI group compared with 56% in the No-ESI group, p < 0.001). There was no difference in primary or secondary outcome measures at four years between the groups. A higher percentage of patients changed from surgical to nonsurgical treatment in the ESI group (41% versus 12% in the No-ESI, p < 0.001).

CONCLUSIONS

Patients with lumbar disc herniation treated with epidural steroid injection had no improvement in short or long-term outcomes compared with patients who were not treated with epidural steroid injection. There was a higher prevalence of crossover to nonsurgical treatment among surgically assigned ESI-group patients, although this was confounded by the increased baseline desire to avoid surgery among patients in the ESI group. Given these data, we concluded that more studies are necessary to establish the value of epidural steroid injection for symptomatic lumbar intervertebral disc herniation.

Epidural steroid injections

Epidural steroid injection (ESI) is the most commonly performed intervention in pain clinics across the United States. This article provides an evidence-based review of ESI, including data on efficacy, patient selection, comparison of types, and complications. The data strongly suggest that ESI can provide short-term relief for radicular symptoms but are less compelling for long-term effects or relief of back pain. Although it has been asserted that transforaminal ESIs are more efficacious than interlaminar injections, the evidence supporting this is limited.

Effect of retropharyngeal steroid on prevertebral soft tissue swelling following anterior cervical discectomy and fusion: a prospective, randomized study

STUDY DESIGN

A prospective, randomized study.

OBJECTIVE

To analyze the effect of local retropharyngeal steroid to reduce prevertebral soft tissue swelling (PSTS) after anterior cervical discectomy and fusion (ACDF).

SUMMARY OF BACKGROUND DATA

There have been several reports on intravenous corticosteroid to prevent airway complication without a consensus; however, there have been no reports to date that have discussed the use of local steroids to reduce PSTS.

METHODS

Fifty cases that underwent ACDF involving 1 or 2 segments were enrolled. The mean follow-up period was 22 months. Of the 25 cases randomly selected as the steroid group, a mixture of triamcinolone and morcellized collagen sponge was applied to the retropharyngeal space before wound closure. For the control group, the other 25 cases received the operation without steroid. We measured the PSTS ratio to vertebral body from C3 to 7 and PSTS index (PSTSI; mean of PSTS ratio at C3, 4, and 5) on cervical spine. Simple lateral radiographs were taken preoperatively, immediately after operation, and at postoperative 2 days, 4 days, 2 weeks, and the last follow-up. The changes in odynophagia, radiological union, Neck Disability Index were analyzed.

RESULTS

The PSTS ratio of the steroid group was significantly lower on C3 and C4 immediately after operation, on C3, 4, 5 and C6 at postoperative 2 days, on C3, 4, and 5 at 4 days. The differences of PSTSI (the steroid: control group) maintained at 58.2: 74.3% (P = 0.004) immediately after operation, 57.9: 84.1% (P = 0.000) at 2 days, 56.3: 82.9% (P = 0.000) at 4 days, and 44.9: 51.4% (P = 0.037) at 2 weeks. The mean Visual Analogue Scale for odynophagia was significantly lower in the steroid group until postoperative 2 weeks. The last follow-up showed no significant difference in the radiological and clinical outcome.

CONCLUSION

Using the retropharyngeal local steroid, we significantly reduced PSTS and odynophagia following ACDF without additional complication. This method may be considered a simple and effective method to decrease PSTS following anterior cervical spine surgery.

Perioperative epidural steroids for lumbar spine surgery in degenerative spinal disease

Object

This systematic review assesses the efficacy of epidural steroids on adults undergoing lumbar spine surgery for degenerative spinal disease.

Methods

The Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, and Embase databases were searched for relevant articles. Search terms included “laminectomy,” “discectomy,” and “steroid.” Randomized and quasi-randomized controlled trials of adults undergoing lumbar spinal surgery for degenerative spinal disease were included. The main outcomes were pain, quality of life, total analgesic agent consumption, postoperative length of hospital stay, the ability to return to full-time work, and adverse events.

Results

Twelve trials (involving 1053 patients) were included. Epidural steroids reduced back pain at 12–24 hours postoperatively (standardized mean difference [SMD] –1.26, 95% CI –2.35 to –0.0.18, p = 0.02), and radicular pain at 1 week postoperatively (SMD –0.71, 95% CI –1.19 to –0.24, p = 0.003) and 1–2 months postoperatively (SMD –2.14, 95% CI –3.47 to –0.81, p = 0.002). Epidural steroids decreased postoperative consumption of analgesic agents (SMD –0.38, 95% CI –0.62 to –0.14, p = 0.002), length of stay (SMD –0.95, 95% CI –1.62 to –0.27, p = 0.006) and the risk of not returning to full-time work at 1 year (relative risk of 0.27, 95% CI 0.13–0.57, p = 0.0006). There was no significant difference in quality of life or in adverse events.

Conclusions

There is evidence that epidural steroids decrease pain in the short term and shorten length of stay in adults undergoing lumbar spinal surgery for degenerative spinal disease. Most of the evidence comes from studies without validated outcomes and that selectively report positive results. More research is required before establishing perioperative epidural steroids as an effective adjunct to surgery for reducing pain in the long term.

Wound infiltration for surgery

Wound infiltration with local anaesthetics is a simple, effective and inexpensive means of providing good analgesia for a variety of surgical procedures without any major side-effects. In particular, local anaesthetic toxicity, wound infection and healing do not appear to be major considerations. The purpose of this review is to outline the existing literature on a procedure-specific basis and to encourage a more widespread acceptance of the technique, ensuring that all layers are infiltrated in a controlled and meticulous manner.

Intradiscal injection of simvastatin retards progression of intervertebral disc degeneration induced by stab injury

INTRODUCTION

Earlier work indicates that the cholesterol-lowering drug, simvastatin, is anabolic to chondrogenic expression of rat intervertebral disc (IVD) cells, which suggests a potential role for simvastatin in IVD regeneration. In this study, we expand on our earlier work to test the effectiveness of simvastatin on disc degeneration utilizing a rat tail disc degeneration model.

METHODS

30 rats that underwent 21 G needle-puncture at rat tail discs were injected with simvastatin-loaded poly(ethylene glycol)-poly(lactic acid-co-glycolic acid)-poly(ethylene glycol) (PEG-PLGA-PEG) gel (5 mg/ml) or vehicle control at 4 weeks after needle injury. All animals were sacrificed 2 weeks after simvastatin injection. Bone morphogenetic protein-2 (BMP-2), aggrecan, collagen type II, and collagen type I messenger ribonucleic acid (mRNA) expression in the rat nucleus pulposus (NP) were measured by real-time polymerase chain reaction (PCR). In vivo magnetic resonance imaging (MRI) was performed to monitor changes in disc degeneration. Rat discs were also assessed by histology using hematoxylin and eosin (H&E) and safranin O staining. In addition, the NP weight, glycosaminoglycan (sGAG) and DNA content were also measured.

RESULTS

A single dose of simvastatin loaded in thermo-sensitive PEG-PLGA-PEG gel injected into the NP had the trend to increase aggrecan expression and sGAG content, and significantly increased mRNA levels of BMP-2, collagen type II, and the differentiation index (the ratio of collagen type II to collagen type I). The decreased NP weight, T2 intensity, as well as MRI index in the rat tail discs induced by needle puncture were significantly reversed after 2 weeks of simvastatin treatment. In addition, simvastatin treatment also improved histological changes induced by needle puncture.

CONCLUSIONS

A single injection of simvastatin loaded in PEG-PLGA-PEG gel into rat tail discs had the potential to retard or regenerate the degenerative disc.